Provider Demographics
NPI:1760294391
Name:JUDY, SASHA MARIE
Entity type:Individual
Prefix:
First Name:SASHA
Middle Name:MARIE
Last Name:JUDY
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:KANNON
Other - Middle Name:MARIE
Other - Last Name:JUDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:252 W BROOKLYN AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-3024
Mailing Address - Country:US
Mailing Address - Phone:801-845-3117
Mailing Address - Fax:
Practice Address - Street 1:252 W BROOKLYN AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-3024
Practice Address - Country:US
Practice Address - Phone:801-845-3117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician